Getting Older and Good Sleep: Do They Go Hand in Hand? - Research on Aging

this ucsd-tv program is a presentation of university of california television for educational and non-commercial use only check out the new youtube original channel you see TV prime at youtube.com slash you see TV prime subscribe today to get new programs every week we all strive to live a long prosperous and healthy life with advances in health and medical sciences this goal is ever more attainable the salmon rose Stein Institute for Research on Aging is a nonprofit organized research unit under the auspices of the University of California at San Diego committed to advancing lifelong health and independence through research education and patient care to better empower and improve the lives of young and old alike the Stein Institute presents the following program let's go right into it and I also I use a lot of cartoons because I think that helps keep you awake and by the way if you fall asleep while I'm speaking I know it means you have a sleep problem it has nothing to do with my talk which is going to be very entertaining so this is one of my most favorite cartoons here's little Marvin and he's playing a game with Grandpa and grandpa falls asleep and Marvin thinks grandpa fell asleep playing with me I better put these someplace for safekeeping and he takes grandpa's glasses and of course it's not the glasses that I care about here it's the fact that grandpa fell asleep while playing a game with his grandson and people think not only that it's funny that's a cartoon they think this is normal behavior just because grandpa happens to be older and the bottom line is the take-home message I'll give you the punchline before I even start this behavior this falling asleep of what we would consider inappropriate times is never normal behavior no matter what the age of the individual so just because someone is older does not mean they should be falling asleep during the day when they really want to be awake so what we're gonna do for the next about 4045 minutes is to talk about why these things happen and what we can do about them so the first point to make here is that there is this myth out there that as we get older we need less sleep I'm sure you've all heard that but if you look at studies that have asked older adults how much they sleep you find that in fact that's not true so what we have here these are data from the National Sleep Foundation which is a nonprofit organization whose mission it is to educate the public about sleep they do a yearly survey and in 2003 they did a survey in older adults so what we're looking at here is data from previous surveys in younger adults who were 18 to 54 that's the blue we have a adults 55 to 64 in the pink 65 to 84 in the yellow and then the combined they considered older 55 and above so the above group are in orange and what we see is during the week the younger adults report sleeping just under 7 hours a night the older adults if we look at the combined are actually sleeping more they're sleeping 7 hours a night on weekends the older adults are still sleeping 7 hours and of course the younger adults are sleeping more because they're making up for all the sleep deprivation that they experienced during the week but the point here is that older adults in fact are not sleeping less than younger adults and we'll come back to that point so although the amount of sleep may not change our sleep architecture the different stages of sleep that we go through during the night do change particularly our slow-wave sleep that's our very deepest level of sleep but what you see is in fact that we start losing our slow-wave or deep sleep in our middle-aged years so even by the age of 30 we have begun losing deep sleep so looking around the room I'd say almost everyone in here has already started losing I'm looking at the younger group here even you have started losing your slow-wave sleep and then it actually stabilizes so as we continue to get older we don't continue to lose our deep sleep our sleep efficiency however does change so what is sleep efficiency this is the amount of sleep given the amount of time that you're in bed in the ideal world that would be a hundred percent right you'd be asleep the entire time you were in bed but it takes everybody at least a few minutes to fall asleep everybody wakes up once or twice during the night so we consider a sleep efficiency of 90% or above to be good sleep efficiency and what we see here if I draw this imaginary line here at 90% you see that with age in both men and women sleep efficiency does drop we also know that those older adults who do have trouble sleeping do have consequences associated with that not getting a good night's sleep is associated with worse memory with worse physical functioning having a harder time getting in and out of a chair as you get older or walking and more depression and depressive symptoms we also know that there's a thirty to forty percent increased risk of falling if you don't get a good night's sleep particularly if you're sleeping less than seven hours a night or your sleep efficiency is less than 65 percent remember we want to see it at 90 or above there's also increased risk of mortality people that sleep less than five hours a night are napping more than two hours a day or have a very low sleep efficiency have an increased risk of shorter survival so not getting a good night's sleep does have what could be considered rather serious consequences so some of these consequences like difficulty with attention difficulty with a slower response time and you know when people think of response time they think oh you're testing how fast I can push a button in response to something flashing on a screen well I like to think of response time is how long it takes you to slam on the brakes when a child is chasing the ball in front of your car that's response time and without a good night's sleep that's slower difficulty with memory etc now these things are found in anybody with difficulty sleeping but in the older adults when this happens what most physicians or your your family think about is not the fact that you haven't been sleeping well they think it's dementia because these are all the same symptoms that we see with dementia and the important point to remember here is it might not be dementia at all it might just be that that person is not getting enough sleep night after night after night now when we talk about difficulty sleeping often we're talking about insomnia insomnia is defined as difficulty falling asleep difficulty staying asleep or non restorative sleep which means you feel like you slept all night but you still wake up feeling tired like it wasn't a good night's sleep but just not being able to sleep at night isn't enough for this definition it also has to have an effect on how you function during the day so if you come to see me and you say you know dr. Hank holy Israel I sleep six hours a night but I'm fine during the day I'm alert I have no problems I can do everything I've ever wanted to do that would not be insomnia but if you come in and see me and you say you know I sleep only six hours a night and I find I'm having trouble remembering or I'm dozing off when I'm trying to read or something like that that's insomnia and when we look at how common insomnia is what you see here is that the prevalence increases with age so by the time we reach our older years about 20 to 25 percent of older adults do have insomnia now the interesting thing about that is that in this very large study of over 9,000 older adults they actually found that 57% had some sleep disturbance but it wasn't chronic so it wasn't a long term but they had some disturbance and then 31% just complained about it but only 12% had no complaints at all but the important part here is those that had the chronic complaints it was almost always associated with some medical problem some poor health and in fact when these people were followed they found that a year later 50% of them that had chronic problems no longer had them and that the sleep getting better was associated with the health getting better and what Foley who conducted the study decided what he concluded was that the data do not support a model of incident insomnia caused by the aging process per se aging on its own does not cause sleep problems if you look at very healthy older adults they don't have trouble sleeping what does cause all the sleep problems is everything else so is it aging that makes sleep get worse no it's not aging doesn't cause the sleep problems but all the other things that happen to us as we get older those are the things that cause sleep problems and what this cartoon says he's being admitted to the hospital she says age and he says I sure do so what are all those things that tend to happen to us as we get older that affect our sleep well medical and psychiatric illnesses all the medications that we have to take for all those medical and psychiatric illnesses changes in our biological clock which we call circadian rhythms and then primary sleep disorders and what I'm going to do is I'm going to touch at least a little bit on each of these so let's start with medical conditions basically any medical condition that causes discomfort can affect sleep at night so whether it's pain from headaches or cancer or arthritis whether it's heart disease any sort of neurological disease just about anything is gonna cause difficulty sleeping and people used to think if that were the case all you had to do was treat the medical problem and the sleep would get better we now know that that's not true we don't necessarily know cause and effect we don't know what came first so what we tell physicians to do is if someone has for example arthritis and they're having difficulty sleeping they should both be treated at the same time the arthritis should be treated with something to take care of the pain the sleep should be treated with something to take care of the sleep and when you treat them both hand in hand you're more likely to get success in both than if you treat for example just the arthritis and hope the sleep gets better so these are associated but not don't necessarily cause the sleep problem this says you shake rattle and roll twist and shout you're tossing and turning all night it's either menopause or too much oldies radio well as weak older of course of course for for us women menopause is an issue menopause does cause sleeping difficulties it's usually the hot flashes that are waking women up at night and there is no easy answer for that one we used to recommend hormone replacement therapy now their problems with increased risk of cancer and other issues with that so that's not used very much anymore so menopause and the symptoms of menopause are a little harder to deal with but know that if you're having difficulty sleeping there's still some treatments that we use for insomnia which I will be talking about before we're done tonight they can also be used for women with menopausal problems and the more medical or psychiatric illnesses a person has the worst sleep is so these are also data from that same National Sleep Foundation survey what we're looking here is people that reported sleeping less than six hours a night that reported any insomnia or that reported excessive daytime sleepiness that's what EDS stands for that's that falling asleep at inappropriate times during the day and the colors here are no medical or psychiatric conditions having just one condition two or three is the yellow or four amours the orange and what you see is especially with insomnia the more medical condition someone has the worse their sleep is so again this confirms the fact that medical and psychiatric illnesses are very much associated with poor sleep and it's one of the reasons that as we get older we have a harder time getting the sleep that we need it's all about that ability to sleep that's changing so here's Marvin again it says he's sitting with his little cousin and he says how come grandpa never goes to a job like other big people because he works at home silly see he runs a drug store another one of my favorite slides the problem is of course it as we get older we have a lot of medications that we need to take and we do need to take most of them for all the other medical problems that we have sometimes we don't need to more medications that we need sometimes someone doctor gave us something and then another doctor doesn't know it and add something else so every once in a while once a year hopefully you have one physician that oversees all your care and you review all that your medications with them and see if there's some you don't need anymore but often you do and the problem is that many of these medications also are associated with poor sleep let's talk for a minute about alcohol which sometimes is used as a medication right so alcohol makes you sleepy initially but several hours later when the alcohol leaves your bloodstream it wakes you right back up again so people that have a glass of wine or sherry for example before they go to bed at night will fall asleep faster but one or two hours later they're gonna wake up and they're gonna be wide awake or if you have a lot to drink with dinner you might be sleepy initially right after dinner but several hours later when it's time to go to sleep you're wide awake and then you have difficulty falling asleep so alcohol is associated with insomnia caffeine you all know that caffeine is a problem with insomnia and you know people will tell me well I can have a shot of espresso before I go to bed it doesn't bother me but if I recorded your sleep and showed it to you you would see that it does and then many other medications Oh nicotine in case you're still smoking and want one more reason to stop here's one more it also causes difficulties and uh with sleep and waking people up at night but many of the antidepressants corticosteroids decongestants you can read the list as well as I can lots of medications that we have to take can affect sleep and sometimes by asking your physician to adjust the dose or the time of day that you're taking that medication will improve your sleep here's a list of drugs that make you sleepy the other ones the other list were drugs that make it hard to sleep this is a list of drugs that make you sleepy so the drugs that are activating are ones you want to take earlier in the day the ones that are sedating are the ones you want to take later during the day close to bedtime so that when they make you tired anyway you'll be ready to go to sleep so think about that and talk to your physician about whether your taking the drug at the right time of day in relation to your ability to be awake during the day and asleep at night okay so we now talked about the fact that medical and psychiatric illnesses sometimes make it harder for us to get the sleep that we need the medications that we're taking make it harder to get the sleep that we need there's also as I mentioned earlier this thing about our biological rhythms or our circadian rhythms circadian means about 24 hours so we're talking about our 24-hour rhythms so blood pressure has a 24-hour rhythm blood pressure takes a little dip at night and then comes up in the morning our core body temperature has a 24-hour rhythm and we'll talk some more about that and of course sleep-wake is a 24-hour rhythm and these rhythms shift or change at different times in our lives and Ben Franklin was wise enough to say early to bed early to rise well that part of his quote really does apply to rhythms and aging and and it'll explain why often when we go to the Opera or the symphony or the theater we see older people dozing off we actually see younger people dozing off but they're doing it for different reason they're just sleep-deprived for us older people it's the timing so let's look at what this means the circadian rhythm for most adults they get sleepy at around 10 or 11 o'clock at night and one of the reasons that's when they get sleepy is their core body temperature drops at that point so as core body temperature drops we get sleepy when it rises we wake up and it rises about seven to eight hours by the way most adults do need seven to eight hours of sleep let me see a show of hands on I do have a little difficulty seeing you because of the light but I'm gonna try so let me see a show of hands how many of you slept seven to eight hours or more last night oh my gosh that's almost everybody that's amazing that's fabulous how many slept six to seven okay five to six less than five okay you're the ones I have to watch out for make sure you're not falling asleep so okay so most adults do need seven to eight and I'm glad to see that most of you got that and and in middle age young and middle-aged most adults sleep from about 11 o'clock to about six or seven the next morning at different times in our lives this pattern shifts so for teenagers how many of you have teenagers or or have grandchildren that are teenagers how many of you used to be teenagers all right so you might remember in yourselves or in your your kids how when you were at you know high school and college age you wanted to stay up half the night and then sleep until noon the next day right and your parents would always say or as parents we would say stop sleeping the day away stop being so lazy you know right turns out that the circadian rhythm in the teenage adolescent years is such that they don't get sleepy till 1:00 2:00 in the morning their core body temperature is not dropping till the early morning hours and adolescents actually need 9 to 10 hours of sleep so if you do the math if they're not going to fall asleep till 1:00 they in fact are gonna sleep till about noon it's very normal physiologically speaking doesn't fit in so much with life but physiologically speaking that's the correct time for them to sleep as they these adolescents grow into adulthood for most of them this pattern shifts back to this standard face some people stay delayed their whole life those are the people that we call owls or night people and they like to stay up late their whole life and they actually have a hard time having jobs where they have to be at work early in the morning because they have such a hard time waking up but most people outgrow that into this normal or I don't it's not a standard phase they're all normal but as we continue to get older that pattern continues to advance so that older adults have what we call advanced sleep face but that means is that core body temperature in the older adult is dropping earlier in the evening maybe 7 8 o'clock in the evening which means that's when we get sleepy and it rises 7 to 8 hours later and again if you do the math if you're getting sleepy and going to sleep at 7 or 8 and you're sleeping 7 or 8 hours what time you're gonna wake up 3 4 5 in the morning right what is the biggest complaint that I hear from older adults I'm waking up in the middle of the night here it is the middle of the night and I can't get back to sleep and you can't because physiologically speaking your night is done it doesn't matter that the Sun hasn't come up yet and it's still pitch black out and these days cold physiologically for your body the night is over so if in fact when we got sleepy at 6 or 7 or 8 we went to sleep we would sleep a full night it just would be out of sync with much of the world or the environment and I have some patients who are advanced and do go to bed early and when they say well I don't know what to do from 4 to 6 o'clock when the rest of the household wakes up take all the shows that you can't watch in the evening because you're sleeping through them and watch them from 3 to 6 in the morning and then you can get up and be up with the rest of the family for most people that will work but two things actually happen one is that people might get sleepy early in the evening but they don't go to bed because they think it's too early to go to bed at 8 o'clock and they want to have a wife you want to go out with your friends you want to go to the theater you want to go out and have dinner so you sort of force yourself to stay up you go to bed maybe at 10:00 or 11:00 but you're still waking up at 3:00 4:00 in the morning because your core body temperature is rising there it doesn't care what time you went to bed it's time to wake up so now you're not in bed long enough to get a full night's sleep so you're tired during the day you might nap in the afternoon because you're tired that nap allows you to stay alert later into the evening but you're still waking up at 4:00 in the morning so you get into this habit of not sleeping enough at night and needing to nap during the day second scenario your home in the evening you sit down you have dinner after dinner you sit down to watch TV or read and what happens you fall asleep and you sleep maybe for half an hour maybe even longer and by the way when I ask patients do you nap in the evening they go oh no because I guess it turns out that sleeping in front of the TV doesn't count as a nap right so but it does for your body so you sleep for about half an hour an hour then you get up and you decide it's time to get ready for bed so you get ready for bed you get into bed and now it happens wide awake you can't fall asleep cuz you just slept so now you're gonna come and see me and say doctor and Koli Israel I have terrible insomnia I go to bed at 10 o'clock at night and I can't fall asleep and I'm still waking up at 4:00 in the morning what's going on and what's going on is that you have an advanced sleep faced with what we call bad habits that is that sleeping in front of the TV early in the evening okay so this is another reason why as we get older we lose the ability to get the sleep that we need our rhythms are advanced and we're not paying attention to that we're still trying to operate as if we were thirty or forty and sleep on that pattern instead of the pattern that our body currently wants now there are ways to shift people's rhythms for that adolescent teenager owl delayed sleep phase we do bright light exposure in the morning so when they wake up they need lots of sunlight I tell parents of teenagers to take the blinds off the windows so that the Sun can pour into the room the more light they have the more it'll shift or advance their rhythm and sometimes we use that in combination with melatonin in the evening I won't go into the details now of how we do that but for advanced sleep phase we want evening bright light the evening light helps do the rhythm that is it helps you stay alert later into the night and sleep later into the morning and what I tell our older patients is go outside as late in the day as possible while the Sun is still out without sunglasses because the mechanism is this the light comes through the eyes and goes right to the brain and it through what's called the retinal hypothalamic tract so if you wear sunglasses you're actually blocking that effect so go at is late in the day as possible without sunglasses go for a nice walk just warmly if it's cold out you can wear a hat if the Sun is still real strong but no sunglasses and get that afternoon light what do most older adults do them when they wake up early they go for an early morning walk which is great because you're exercising but that early morning light is going to advance your rhythm even more it's gonna make us get sleepy earlier and wake up earlier so I don't want to tell you not to walk in the morning it's okay but in the morning on your morning walk where your dark sunglasses and then go back out again later in the day without sunglasses to get that late afternoon light okay so now we've talked about the medical and psychiatric illnesses the medications the circadian rhythms all being reasons why we have a hard time getting the sleep that we need now I want to move to some of the primary sleep disorders that are quite common and become more common as we get older and the first one is called sleep disordered breathing or sleep apnea this is a condition where people stop breathing in their sleep for periods throughout the night essentially they fall asleep they stop breathing then in order to start beating they wake up so they wake up they start breathing they go back to sleep they stop breathing and these awakenings during the night are so brief that they don't realize often that they're waking up to of the symptoms as you see here one is excessive daytime sleepiness that falling asleep at inappropriate times this is a picture I took when I was in Vienna quite a few years ago it's a picture of Brahms sort of appropriate right here at the lullaby and here he is sleeping but I also think he must have had sleep apnea why do I think that first of all he's overweight that is often a symptom sleep apnea he has a beard which is covering his double chin another symptom or suggestion of sleep apnea he's older the older we get the more likely it is that we have sleep apnea and he's sound asleep who has a statue made of them sound asleep right so I'm convinced he must have had sleep apnea so this daytime sleepiness being overweight are some of the symptoms the other symptom is this one here this loud snoring and we asked our patients how loud do you snore can you be heard only in your bedroom can you be heard one room away are you a one room snore are you a two room are you a three room can your neighbors hear you and sometimes they'll say yes so this is we're talking about a very very loud snoring and just to point out that it's not just the men that snore so this cartoon says Adam did I snore it again last night and he's got earplugs in his ears women do snore we snore quite loudly at times the older we get the more we snore sleep apnea is also quite common in women particularly postmenopausal but the prevalence is still more common in men so more men than women snore loudly more men than women have sleep apnea but don't think that just because we're women we're immune to that the prevalence of sleep apnea does increase with age that's what this graph is showing you and the prevalence in older adults is about close to 50% so about half of older adults have some amount of sleep apnea and the reason this is important is because it is also associated with risk this is a large study it actually this particular part of it was only 400 people but this is actually a study of over 3,000 older women we have another study similar to this in over 3,000 older men with similar data which showed that those who had sleep apnea had one and a half time so if they had mild apnea that is they stopped this number is the number of times they stopped breathing per hour of sleep anything five or less is normal so 15 is considered mild those with mild apnea had one and a half times the risk of being cognitively impaired those with severe apnea had three and a half times the risk of being cognitively impaired and when their oxygen dropped during the night because they weren't breathing to less than 80% they were also three times as likely to be cognitively appeared in a second study this was now a prospective study where we looked at women who had sleep apnea but were not cognitively impaired and we followed them for five years to see who would develop dementia or mild cognitive impairment and what we found was that those with sleep apnea were more likely to develop dementia than those without sleep apnea this is untreated sleep apnea and again those whose oxygen levels dropped were more likely to develop dementia but those who had difficulty with sleep had disrupted sleep but didn't have problems breathing were not at greater risk for developing dementia and what the authors I was one of them what we concluded was that at least for older women sleep apnea is very common and is associated with least a two time increased risk of developing cognitive impairment five years later and these findings suggest that it's really the oxygenation or lack of oxygen during the night that's putting us at risk and it makes sense right you're not getting oxygen to the brain something's going to happen there is a treatment for sleep apnea it's not very pretty but it works it's a machine there different kinds it's called CPAP or continuous positive airway pressure and essentially it's a mask of some sort there are all different kinds connected via a hose to this machine which pushes positive pressure through the airway you can see that here which acts as a splint to keep the airway open during the night and so the patients that use this are able to sleep all night long they're able to breathe all night long and they get all the oxygen that they need to their brain now you might wonder will an older adult use this and why should they use it so these these are results of a study that we conducted in patients who had both Alzheimer's disease and sleep apnea and we treated their sleep apnea this is actually one of our patients and what we found was that the CPAP did reduce their sleep apnea to normal levels it made their sleeping deeper so they were able to get into their deeper levels of sleep they were less sleepy during the day and it improved some aspects of their cognitive functioning and long-term use when we looked at those that used it for six months or longer compared to those that didn't they were still deteriorating we're not curing Alzheimer's disease here but we were able to slow down the deterioration so imagine if it has that kind of effect in patients with dementia imagine what it would do to you when you don't have dementia but you have sleep apnea it might prevent dementia from occurring it also sleep apnea is also associated with increased risk of heart disease hypertension stroke and early death so all good reasons if you suspect you have it to get it treated it is not a disease of aging we have we see it in all ages including children but it does become more common as we get older and so it's important to identify okay here's another cartoon that says I dreamt I was driving down a mountain road and the brakes failed and he's pushed out the the bedframe well this is actually a symptom of another sleep disorder called REM behavior disorder before I describe it to you I want to read you this case a 60 year old surgeon began to punch and kick his wife and jump out of bed during nightmares of being attacked by criminals terrorists and monsters who were always trying to kill me work-related stress was the presumed cause of the sleep disturbance but the violent behaviors intensified despite retirement three years later he sustained several head lacerations his wife once had a severe headache for two days after receiving an accident blow to the ear proper diagnosis was established after 11 years can you imagine sleeping with this for 11 years and a pro drum of excessive limb movements and body jerking during sleep had been present for 33 years REM behavior disorder is a disorder where people act out their dreams during our dreams sleep we are paralyzed except for our eyes and our respiration and this is actually a protective mechanism to keep us from acting out our dreams so if your dreaming that you're playing tennis this is what keeps you from swinging your arm and hitting your bed partner yourself people with REM behavior disorder have lost that paralysis during room and they do act out their dreams and they often do hurt themselves or their bed partners they could be the most gentle Souls when they're awake it's not something they can control but in their sleep they start becoming very violent this disorder is most common in older men we rarely see it in women although it does happen mostly in older men so if you're sleeping with someone that is acting out you need to mention that to your physician because there is a treatment there's some very effective treatments to it with medications but they work very very well and that person will start sleeping much better and the bet partner will start sleeping much better ok another cartoon this is a Earl and opal and opal sound asleep cats sleeping on her feet suddenly the cat goes flying and Earl says opal this cat's getting too darn frisky well it's not the cat it's opal opal has a sleep disorder called periodic limb movements and sleep this is a disorder where people kick or jerk their legs every 20 to 30 seconds for periods throughout the night says if every time you fell asleep someone came over and shook you just enough to wake you up again and the bed partners here complain of being kicked all night long so people with sleep apnea sleep in separate bedrooms because it allowed snoring people with periodic limb movements to sleep sleep in separate beds because they're tired of being kicked all night long there is a related disorder called restless leg syndrome so this says you look more worried Pierce pet problems don't tell me your rat is back in the hospital no no he's fine the tail transplant was a total success great so what's the my centipede has a restless leg syndrome restless legs is a disorder where people get creepy crawly uncomfortable symptoms in their legs they describe it as if ants are crawling up and down the inside of their legs and the only way to relieve that movement is that relieve that under that sensation is by movement so these people will be pacing or shaking their legs all the time constantly moving to get rid of that sensation the prevalence of both restless legs and periodic movements also increases with age here every color is another study and the ages across the bottom you can see in just about all of them the prevalence is much higher in the older adults than in younger adults we don't know a lot about what causes these disorders we think it has to do with the dopamine system in the brain but we do know that we see it a lot in patients with diabetes with peripheral neuropathy chronic alcoholism Parkinson's disease kidney failure etc etc etc I want to especially point out the iron deficiency sometimes we always test for iron and if there is an iron deficiency sometimes the best treatment is just an iron supplement but there are all these things that are associated with increased risk of restless legs and the way you know if you have it is if you answer yes to all four of these questions than anything who's evaluating for restless legs should be asking you these questions so the first is do you have or have you sometimes experienced recurrent uncomfortable feelings or sensations in your legs while sitting or lying down so it has to do with when you're being still you get these uncomfortable sensations do you have or have you sometimes experienced a recurrent need or urge to move your legs while sitting or lying down so it becomes so uncomfortable that you have to move and you just can't keep them still do these uncomfortable feelings or sensations or the need to urge or need or urge to move disappear or improve when you are active or moving around so does the movement actually make it feel better and are these uncomfortable feelings worse than the evening or night as compared to in the day because it does get worse as the day goes goes on if you answer yes to just one of these two or three you don't have restless legs but if you answer yes to all four then you do and there are treatments for restless legs as well they're all medications most of them are dopamine agonists it's actually the same medications that we use to treat Parkinson's disease although this is not Parkinson's disease there's some other newer medications as well but more importantly I want to show you that there are medications that actually will make restless legs worse or make you experience that even when you don't have it otherwise and those would include some of the over-the-counter sleeping pills antihistamines such as benadryl or dimetapp some of the anti-nausea medications calcium channel blockers certain antidepressants and certain antipsychotics so if you do have restless legs again you need to talk to your physician about what medications you're taking to see if the medications are making it worse alright so what about insomnia now now insomnia of course as we said it's difficulty falling asleep or staying asleep and even with some of these other disorders that we've talked about the person may be complaining of insomnia but sometimes it's insomnia separate from the sleep apnea or the restless legs or anything else and then it's time to just treat the appian hopefully when you talk to your doctor about having insomnia the response is not well I wouldn't lose any over it so before I talk about the treatment I want to give you a little background about how sleep works because this will help you understand why the treatments I'm going to tell you that works so sleep is controlled by what we call the to process model part of that is our sleep drive or a homo static drive or our need to sleep and the other part is a circadian system which we've in part talked about when you wake up in the morning your sleep drive or that need to sleep is very low because you've just been sleeping right as you go throughout the day the longer you're awake the more that sleep drive increases though the longer that we're awake the more we then need to sleep until that need gets so great that you fall asleep and once you fall asleep the need to sleep decreases because you're sleeping what keeps you from falling asleep in the early evening or afternoon as your sleep need is increasing it's the circadian a learning system that counteracts that sleep drive until they get to this balance point and then you fall asleep and that also begins to decrease the other things that control our sleep as we mentioned earlier is our core body temperature remember we said it drops that's when you get sleepy it rises that's when you wake up but look what happens in the afternoon core body temperature takes a dip in the afternoon that's why we get sleepy after lunch taking a siesta physiologically speaking is the most normal thing to do it just doesn't fit in very well with our society but clearly the whole societies that do that but if you look at the cultures that sleep in the afternoon you find that they go to bed much later at night than we do they have dinner much later at night than we do so in a 24-hour period they're sleeping the same amount that we do they just do it in two bouts we tend to do it in one and biologically speaking the way they do it makes more sense because our body wants to take a nap in the afternoon and there is nothing wrong with taking a short nap in the afternoon as as it doesn't interfere with your ability to go to sleep when you want to at night but if you are going to take a nap in the afternoon you want to limit it to 30 minutes you know that feeling when sometimes you take a nap and you wake up and you feel worse than you did before you went to sleep that's called sleep inertia that means you wake up and you just it just takes a little longer to get going again if you sleep only thirty minutes you won't experience that sleep inertia so if you limit your nap to thirty minutes in the early afternoon you'll wake up feeling refreshed and you're less likely also to have it interfere with your nighttime sleep the other part of our sleep control is melatonin melatonin is a hormone that's produced in our brain you've heard of melatonin because it's also sold over the counter I'm not talking about that melatonin I'm talking about the one we make in our brain and it is secreted at night in darkness and it helps us sleep and that darkness is important we'll come back to that in a minute as well the other part of insomnia is what we call the 3p model and this has to do with the predisposing factors the precipitating factors and the perpetuating factors of insomnia so what this means is if you happen to be an anxious type of person or a depressed type of person if you worry a lot about anything but particularly about sleep you know what what happens to the insomnia oh my god you know I didn't sleep last night what's gonna happen I know when I go to bed tonight I'm not gonna be able to sleep and that anxiety makes sleeping harder and harder or if you have a decreased drive to sleep that sleep drive we just talked about if you have those things that predisposes you to having insomnia doesn't mean you will have it it just means you're more likely to get it and you're more likely to get it if you're hit by one of these precipitating factors which would be the medical illnesses the medications something like that but even that won't necessarily lead to chronic insomnia what leads to chronic insomnia are the perpetuating factors and those are all the things we are doing that we think help our sleep that actually make it worse what I call very bad habits and what we've learned is that by using behavioral therapies we're able to break that connection we're able to get rid of those four Pecha weighting factors so that people can learn to sleep again and that's what I want to talk about now a little bit is these behavioral treatments for insomnia so in 2005 the National Institutes on Health had a state of the science conference on insomnia and they concluded that the behavioral therapies were as effective as prescription medications and actually the beneficial effects of the behavioral therapies lasted well beyond the termination of treatment which you can't say for the sleeping pills so behavioral therapies are actually the very best treatment we have for insomnia and what most of the behavioral therapies essentially do is they take that association that you've created between your bedroom and worrying which causes anxiety and breaking that so you start associating the bedroom with the cue for falling asleep so you associate the bed with sleep rather than associating the bed with oh my god I'm having such a hard time falling asleep I know my god is only two hours left and now there's only one hour left and all the other things that we do in our heads when we can sleep so part of it is what we call good sleep hygiene how many times have I told you no coffee after September so what we say is no coffee after lunch remember we talked about caffeine making hard to sleep if you have insomnia no coffee after lunch exercise this says I toss and turn all night and you won't count that as an eight-hour aerobic workout no the more you exercise the better you sleep doesn't mean you have to run a triathlon just go for a walk even if it's one block whatever you can do if you do that you'll sleep better in the ideal world we would exercise six hours before we want it to go but doesn't always fit in with our schedules but why six hours when you exercise your core body temperature goes up remember we said when it starts dropping that's when we get sleepy when it's up there from an exercise it takes about six hours to start dropping so if you could exercise six hours before bedtime you an easier time falling asleep keeping your environment very comfortable and very dark and very quiet and the dark is because of that melatonin secretion when you turn on the light that inhibits melatonin it tells your brain time to get up okay you don't want that you want melatonin to be secreted at night so you can sleep better so you want your bedroom as dark as possible you know how when you go to hotels and you have blackout curtains you sometimes sleep longer it's because of that darkness so you want it as dark as comfortable and temperature is you know not too hot not too cold whatever it's comfortable for you okay when you wake up in the middle of the night what's the first thing you do call it out let me hear it go to the bathroom wrong I bet even before you go to the bathroom you look at the clock right worst thing you can do what do you have to do when you look at the clock you have to open your eyes you have to turn your head you have to lift it and you have to take yourself from transitional sleep to full awakening to comprehend that it's 1:20 in the morning and you want to be asleep what have you just done remember our balance remember that homeostatic sleep drive you have to be awake a certain amount of time before you're gonna be sleepy enough to fall asleep well by taking yourself to full awakening it's now harder to go to sleep back to sleep because you haven't been awake long enough to be sleepy enough to fall back to sleep so when you wake up in the middle of the night what you want to do is nothing don't even open your eyes and then you have a much greater chance of falling right back to sleep the only way to avoid or to keep yourself from looking at the clock is get rid of it there is no reason to know what time it is in the middle but not you need an alarm clock stick it under the bed stick it in a drawer where you're not tempted to look at the time okay that's the number one rule of anybody with difficulty sleeping but now you're gonna tell me but when I wake up I have to go to the bathroom well it turns out needing to go to the bathroom doesn't wake you up usually you wake up first and once you're awake you realize their pressure and so you figure oh I have to go to the bathroom so if you could go right back to sleep you might not even need to get up to go to the bathroom if you do nay to get up what you want to do is not turn on the lights again remember light says to the brain no melatonin go what time to wake up so you want to keep it as dark as possible you don't want it to be a dangerous situation so maybe a nightlight I love these I saw this in a magazine on an airplane I think it's I should have bought a pair I didn't I think it's the most brilliant thing right you could see where you're going and not have to turn on the lights so if you don't have one of these at least get a nightlight but try not to turn on all the overhead lights when you get up to go to the bathroom what other good sleep habits do we encourage setting a regular time so going to bed and getting up at the same time every day that means no sleeping in on Sunday mornings now people always groan when I say that if you don't have trouble sleeping I don't care what you do if you do have trouble sleeping you have to adhere to these rules you also don't want to spend too much time in bed the more time we spend in bed the more fragmented and disturbed our sleep becomes the less time in bed the more consolidated so seven and a half hours of sleep out of eight hours in bed is much more efficient than seven and a half out of nine or ten hours in bed what is the insomniac patient do I didn't sleep a wink last night I'm gonna go to bed two hours earlier to try to get more sleep now they're extending their time in bed and making their sleep even worse so don't spend too much time in bed in our busy lives often the first moment we have to sit and think is when we get into bed at night and that's the wrong time to start thinking so we tell people to set aside a worry time I know this sounds silly it is very effective find 10-15 minutes during the day same time every day when you turn off your cell phones and you don't let anyone bother you that's your time to sit and worry it's your time to sit and think about all the things that you tend to think about in the middle of the night what do I have to do tomorrow is my daughter gonna find a job what's gonna happen you know all those things that worry us if you do it at the same time every day not too close to bedtime you start freeing yourself up from having to do it at night and if you do start doing it not you can remind yourself I have from 10:00 to 10:15 tomorrow to do this I don't need to do it now it works try it it works okay napping we already talked about the fact if you're gonna nap do it an early afternoon for 30 minutes increase your exposure to bright light remember we talked about how bright light can be used to shift rhythms but we also need a lot of light exposure during the day to just have good sleep at night unfortunately most of us spend most of our days in dark rooms unless you standing here with a bright light in your eyes I'm getting lots of bright light right now so you want to get outside without sunglasses during the day and get good light exposure avoid having heavy meals or drinking too much too close to bedtime avoid alcohol and nicotine too close to bedtime we already talked about the issues with alcohol and sleep so if you do these things that alone will help you sleep it's not often sufficient if you have real insomnia often need some other behavioral treatments as well but this is a good start for improving sleep now sometimes you do need to take medications sometimes taking sleeping pills are very appropriate but there are lots of different sleeping pills out there and different things that are used for sleep one of the most common are the over-the-counter PM drugs they have diphenhydramine in them antihistamines and the advantages are that you can buy them over-the-counter they're cheap and because you can get them over-the-counter people think well they must be safe finally in prescription for thing must be a safe drug turns out not so true especially as we get older so the disadvantages are the dose is not well defined we don't know what the right dose is most of the pills come in about a 25 milligram we don't know if that's too much or not and often within a week you develop a tolerance that is that one pill isn't going to work anymore there are also side effects to these pills they do make you sleepy sometimes way into the daytime in the morning hours even after you've woken up they can result in a dry mouth loyd vision urinary retention sometimes dizziness or confusion there was one study that was done this was a study on older adults who are in the hospital these are not demented older adults these are regular older adults like you and me or in the hospital for all the reason that reasons we have to go to the hospital and they were given 25 to 50 milligrams of diphenhydramine and what they found was these patients had more symptoms of delirium inattention disorganized speech altered consciousness agitation all these things that look like dementia don't they but really aren't so you know if you have trouble sleeping and you take this once in a while it's probably okay but this is not a drug that you want to be taking every night at our age because it has possible side effects and is not the best thing that you can take for sleep and what the NIH conference said was the antihistamines no evidence for efficacy and significant concerns about the risks they also said that antidepressants which people often use for sleep as well because some of them are very sedating can have potentially significant adverse effects raising concerns about the risk benefit ratio and they said barbiturates which I hope no one is taking or antipsychotics have significant risks and should not be used for insomnia if someone is psychotic they should be taking antipsychotic medication if someone has insomnia they should not be taking antipsychotic medication the Annina medication for insomnia you should be taking a sleeping pill which is approved by the FDA for sleep and there are actually they're there about 12 of them at least 12 of them now some of them are older and have been around for a long time and can be very sedating and are not recommended very much anymore the newer ones what you see listed here are the ones that are recommended more often these days but even with these there's a time and a place and a way to take them so the first question you should be asking yourself or your physician should be asking you is what is your difficulty is it difficulty falling asleep or stay sleep and how many hours will you stay in bed how many hours can you afford you have time to stay in bed because for example a Zampa clone which is lunesta is approved for falling asleep and for staying asleep so he could be used for either of those problems zal a plan which was to not have announced generic so it's a plan again is only for initiating sleep and it has such a short half-life that it can be used for taking in the middle of the night even though it's not approved for that that would be off-label but as long as you have four hours left in bed you can still take it ambien zolpidem is only for falling asleep it is not approved for keeping you asleep ambien cr zell put in modified release is approved for both falling asleep and staying asleep rose Arum which is Rimmel Tionne is only for falling asleep doxepin which is silent or is for maintaining Segen actually there are two other drugs I just I just realized they were recently being approved that I don't even have on here one is specifically for middle of the night use so you have to look at what the indication of the sleeping pill is and what your complaint is and match the right sleeping pill to your complaint but now let's look at this last column you can see that for many of these you need to be in bed 7 or 8 hours and if you're in bed less than that there is a possibility that you'll still be sedated when you wake up in the morning and then it becomes a hangover right then it becomes a drug hangover so you have to be careful with these pills they are all very safe and effective when used correctly and that's the part I underline and emphasize when used correctly so if you're using this make sure you review how they should be used and that you are in fact using them in that way so to summarize getting older and good sleep do they go hand-in-hand they can aging on itself doesn't cause sleep problems but all the other things that accompany aging can in fact make it harder for us to get the sleep that we need but the good news is for all these things that make it harder to get our good sleep where there are things we can do to make them better and so what I hope for you oh and I have to show you this quote aging seems to be the only available way to live a long life so I wish you a continued successful aging I wish that you live a long life and I wish for you that it is filled with many good nights of sleep thank you

Channel: University of California Television (UCTV)

Views: 85,792

Rating: 4.6523561 out of 5

Keywords: sleep, aging and sleep, sleep disruption, insomnia, Dr. Sonia Ancoli-Israel, Stein Institute on Aging

Id: 5qFOuLyb7K8

Length: 59min 28sec (3568 seconds)

Published: Thu Mar 01 2012